What do Patients Need to Know About Referrals?

Many patients who see specialists at American Family Children's Hospital (as well as UW Hospital and Clinics) outpatient clinics need referrals to do so.

Types of Referrals

Doctor-to-doctor referral: The patient's primary care provider (PCP, or family doctor) requests the patient be seen by a specialist at American Family Children's Hospital.

Insurance referral: If the patient is covered by a health maintenance organization (HMO), the HMO must approve an insurance referral to consider the service for payment. Without an approved insurance referral, insurance will not cover the cost to see the specialist. When HMOs review referral requests, they approve (or deny) specific services for a specific time period or number of visits. It is important for the patient to understand the services their HMO has approved in the referral. For example, the patient's HMO may approve a visit to the specialist but require the patient to obtain lab and radiology services from their PCP.

Important Information About Referrals

Patients should always talk to their primary care providers before scheduling appointments with American Family Children's Hospital specialists.

If the primary care provider believes a consultation with a specialist is needed, the primary care provider will initiate the doctor-to-doctor referral.

Patients should provide accurate insurance information to primary care providers so the PCP can initiate the insurance referral.

On occasion primary care providers will ask patients to provide some of the referral information, including insurance codes. Contact UW Health customer service at (608) 262-2221 or (866) 841-8535 to obtain insurance codes.

Patients who see specialists without referrals may be responsible for full payment for the care provided.

Questions about insurance coverage should be directed to the patient's insurance customer service department.

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